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16-20 Segment 1: Homeless Medical Care

Homeless Americans have a life expectancy of only around 50, and often use the ER for primary care at a huge cost. The lack of followup care for their illnesses and the mental health or substance abuse disorders common in this population add up to an enormous health burden. Experts discuss how doctors on the street can improve health for the homeless and lower cost for society.

Reed Pence: Nobody really knows the number of homeless in the United States. The federal government estimates that on any given night, about 600,000 Americans will be homeless. Over the course of the year, as many as three million people may experience homelessness at least for a while. And even though the homeless are increasingly visible, most of them would prefer not to be.

Dr. Jim Withers: I was first of all shocked at how many people were actually tucked into the nooks and crannies of Pittsburgh – a lot of people were hiding, trying to not be that noticeable and others not so much, but just this vast array of humanity that I hadn’t been aware of.

Pence: That’s Dr. Jim Withers, medical director and founder of the Pittsburgh Mercy Health System’s Operation Safety Net and the Street Medicine Institute. He’s spent more than two decades meeting the homeless out on the street caring for their health.

Withers: Their health conditions were poor. It didn’t take me long to realize that virtually none of them had primary care. There was untreated hypertension or people with cancers, there were people with large venous ulcers with maggots in their legs, people whose wounds were festering. It was like going to a third world.

Dr. Jim O’Connell: I thought we were seeing very complicated medicine in the hospital. People were coming from all over the world to Mass General, which is a pretty wonderful hospital. I have loved it. So when I went to the community I thought it was going to be easy, that I would have a year of getting to know people and doing the kind of medicine I was used to. It took me no more than ten minutes to realize that this was way more complicated and more complex than I had ever dreamed. The first thing that was apparent was infestations with lice, scabies and bedbugs. All of those things were the first time I’d encountered them in big droves.

Pence: Dr. Jim O’Connell is president of the Boston Healthcare for the Homeless Program and author of the book, Stories from the Shadows: Reflections of a Street Doctor. He says that despite bedbugs and lice, most of the diseases he treats among the homeless seem pretty much like anyone else’s.

O’Connell: It was pretty much every day common illnesses that I had been trained to take care of. Because after all, homeless people have the same kinds of issues – hypertension and emphysema, they have rheumatoid arthritis, they have all sorts of issues going on that I had been used to seeing. What I was unprepared for though, was that these were folks who had had these chronic conditions for years and had not got any care. So I was seeing for once the natural history of disease unencumbered or untreated by the medical system. So almost everybody I knew had been in care. These people that had the same illnesses that had been out of care for years and the devastating long-term effects were vividly apparent.

Pence: Depending on the estimate, someone in chronic homelessness can expect to live only until his late 40’s or early 50’s. Withers say if it were a recognized world health organization diagnosis, being homeless in America would be one of the worst illnesses a person could have. That’s because overlaid on all the typical health problems are often a variety of mental health issues that aren’t the norm in most patients.

O’Connell: These were people who were suffering from enormous burdens of medical problems complicated by mental health issues, complicated by substance abuse issues. And I’m sure is the long-term effects of having grown up in just the worst of circumstances — the most abject of poverty, in foster care, kids that had ADD that wasn’t recognized and were seen as trouble makers so they never did well in school, many didn’t learn how to read or write, very few came from intact families. Many of the homeless folks you’ll see will have suffered terrible abuse as children – physical, emotional, sexual. So you realize that the people who have lost in what I think of as the musical chair game of getting housing, how frequently those people who are struggling with the most challenges. I just never thought about the complicated social determinates of health the way I got handed it into my face when I worked into the clinic at the shelter

Withers: It’s a matrix of things that are all interacting – mental health, prior trauma, molestations when they were kids, addictions that have settled in, mental health disorders are very prominent out there. But physical disability also leads people to be unable to participate in the workforce and chronic illnesses are out there. So it’s all these things interact. And much like with domestic violence victims, people over time lose hope; they just survive one day to the next. So it’s that perspective that people have that, I’ve tried everything I can do and I can’t get out of this situation, I’ll just survive today and that’s all I’m going to think about.

Pence: But if street people are in survival mode and ignore health problems long enough… they usually end up in a hospital’s emergency department… where they may rack up enormous medical bills.

Withers: In Los Angeles, twenty-three percent of the homeless use the emergency room as their primary care. In San Francisco forty percent have used the emergency room in the past year, which is three times the national average. Even here in Pittsburgh our busiest hospital Mercy Hospital, I looked at the data and thirty-four percent of the highest utilizers of our emergency room are part of our street population. They’re often uninsured, unless you have targeted program to get them insured and it’s really a wasteful way to deliver healthcare.

Pence: In a study from the University of California San Diego about 15 years ago, researchers tracked more than 500 homeless chronic alcoholics for three years. They found that over that time, those patients landed in the emergency room more than 3,300 times and accumulated a total healthcare bill of nearly $18 million. And O’Connell says those costs are only the beginning.

O’Connell: I’ve learned that not only are homeless people suffering from the severe burden of illness for which we as a society are paying a heavy price in hospital costs, emergency room costs, police costs, but those costs really are significant to society. I look at it as the cost of doing nothing about that problem. I think any money we can invest in addressing the problem is likely to be something that if it doesn’t save money it clearly will improve health and quality of life not only for homeless people but for all of us.

Withers: I’m a proponent as long as unfortunately we do have people sleeping in the streets, that every community should have a street medicine program. This is what the Street Medicine Institute is all about. We’ve help start or connect fifty or so programs throughout the United States that are approaching people with this same philosophy of being there with them. To me it’s a fundamental requirement if you’re going to work with people who are now increasingly seen as not part of society, that may self-identify that way, you need a special approach to make that connection. You need respectful ways to create a welcoming non-judgmental face to healthcare so they can walk through that door.

Pence: However, some street people will never walk in to a clinic. and if they ever see a doctor, they’ll never get follow-up care. They have more immediate, important things to do.

O’Connell: If you need to get a bed tonight and your next meal and you have to stay safe from the elements and you have to avoid being picked on or something like that, your struggle to survive out on the streets and in the shelter means that you are caught in an immediacy that doesn’t let you think about long-term effects of any illness you have, or of even making appointments down the line. You have to survive.

Pence: That’s why doctors for the homeless and other health care workers know they have to be out on the streets… practicing a different kind of medicine. O’Connell says veteran street nurses like Barbara McInnis warned him that he’d have to slow down and get to know people.

O’Connell: That requires taking time with people, it requires never judging them, it requires sharing a bit of yourself, it requires having a cup of coffee, but mostly it involves listening and a consistent presence. Those are all the things that we rarely get to do when you’re in a hospital or clinic setting where things have to go so fast. And Barbara would turn to me and say, if you don’t establish that trust she said, then you will never have any continuity of care and you’ll never get people to do any of the things that you need them to do. And she was so right. Most people didn’t tell me anything the first week, some not for the first month, some not for the first year. But as I became more and more part of the fabric of the shelter and the streets then people would begin to trust you and slowly they’d share their stories with you.

Pence: O’Connell says until doctors know the stories of the homeless… there’s really no way to work around their scars and paranoias to treat them. Withers agrees. In fact, he wishes every patient could be treated in much the same way — at a slower pace where listening is most important.

Withers: Taking that time, it’s an investment perhaps in the way things are scheduled now, but just sitting with them and looking them in the eye and listening, letting them explain who they are. That’s important everywhere, but it’s particularly important on the street because they have a huge deficit in terms of receiving any sort of respect. I have people when began to listen to them by the campsites and riverbanks who would just break down crying saying I can’t believe someone cares that we’re still alive here. The power of just listening opens things up. If you respect someone and give them a sense that they have control in this relationship over their own autonomy, their own care plan, then they let their guard down and they let you actually be part of that, and they begin to trust you. But up until that point there’s a lot of fear and mistrust, so it’s just a matter of investing time with people.

Pence: But even then, how can the homeless ever manage the follow-up care that’s required to treat major illnesses? Sometimes it takes the entire community, as O’Connell found when tuberculosis was diagnosed in more than 60 homeless people in central Boston. Treatment of this particularly resistant strain required four medications administered daily for 18 months… seemingly a recipe for failure. But if medics have personal relationships out on the street… amazing things can happen.

O’Connell: Even though the whole picture looks chaotic, the life of each individual homeless person tended to be more ritualistic than not. So most people kept to the same geographic area, stopped in the same places at their lunchtime, went to the same library or bar or something in the afternoon. We had to learn patterns of each individual, and as you started to learn that, the chaos dissipated into a semblance of some order. We’d have to get on our bikes – this was in 1985 – get on our bikes and go find them on the street corners where they would be. We also learned that a few of them would use a particular bar and we’d go to the bartender and ask the bartender when they show up in the afternoon can you call us, we’ll come down and give them the medication. In a few instances the bartender was willing to keep the medicine in a little cabinet there. So when the people came in he’d bring it over and they’d take it out of the little bottle and he’d put it back. The bartenders and the barbershops and all sorts of people in the community became our eyes and ears to treat this.

Pence: That’s a success story, but O’Connell says they happen too seldom. He and Withers say if street people can only get into housing, then they have safety and routine that can begin to ease their medical problems as well.

Withers: When we get people into housing, I have watched over time their ability, it doesn’t happen right away, but their ability to embrace the things that they need to get into a healthier place is much easier for them because they are not afraid of someone murdering them in the night. They don’t have some of the distractions on the street. They’re not in a survival mode, basically. And with the right team they don’t feel dropped either. They feel like they have people they can trust. Over time they do better. It’s miraculous actually to see how much of a factor housing can be in providing better health.

Pence: The homeless have so many factors going against them that Withers admits he’s had times of despair. But he says the rewards are priceless, and a reminder of our shared humanity. According to a lot of economists, most Americans are themselves just one paycheck away from the street.

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